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A. Riera March, MD

Otolaryngology-Head & Neck Surgery

Any comments or questions regarding this Website, please notify at ariera@spray.no

Case Presentation: Cervical Cystic Hygroma

No. 1

Pictures

Case Presentation (Cervical Cystic Hygroma)

History

A 11-year-old patient was referred to our OTO-HNS

Clinic due to a right sided neck mass noted

approximately 2 months prior to be seen in

our service. The patient was otherwise asymptomatic.

Physical

Examination

Soft neck mass localized in the right carotid triangle of the neck.

CT scan with

contrast

Coronal and axial CT images of the neck after contrastmaterial enhancement.

The images reveal a lateral neck mass localized basically in the right carotid triangle of the neck with medial extension towards the retropharyngeal structures.

(CT-1 Click here to enlarge the picture)

(CT-2 Click here to enlarge the picture)

Procedure

(1)

Transversal skin incision over the mass in the right

side of the neck. Subplatysmal plane developed

above and below the lesion.

(Surg-1 Click here to enlarge the picture)

(2)

(2)

Wide exposure accomplished. The proposed surgery will require a neck dissection at level II, III & IV withexcision of the mass.

The sternocleidomastoid muscle is seen lateral to the

internal jugular vein. The mass is retracted medially

with a clamp and the internal jugular vein is seen

attached to it.

(Surg-2 Click here to enlarge the picture)

(3)

(3)

The retractor is displacing the sternocleidomastoid

muscle for better exposure. The internal jugular vein

was dissected free from the mass. (gauze and

surgeon’s finger are retracting the superior aspect

of the vein).

The vagus nerve is seen as a “white cord” running

parallel to the internal jugular vein. The mass is still

attached to the axis of the carotid artery.

(Surg-3 Click here to enlarge the picture)

(4)

(4)

The internal jugular vein and vagus nerve are seen as

described previously laterally. The mass is still partially

attached to the carotid artery.

(Surg-4 Click here to enlarge the picture)

(5)

(5)

The dissection proceed just below the submandibular

triangle.

The posterior belly of the digastric muscle is seen

clearly in the superior aspect of the surgical created

wound. The hypoglosal nerve is attached to the mass

which is retracted inferiorly with the surgical clamp.

(Surg-5 Click here to enlarge the picture)

(6)

(6)

The surgical specimen just before the separation of the

final attachment.

(Surg-6 Click here to enlarge the picture)

(7)

(7)

Surgical wound aspect after the mass was removed.

From lateral to medial: sternocleidomastoid muscle,

internal jugular vein, carotid artery, and the opening

where the mass extended medially towards the

retropharyngeal structures.

In the superior aspect, as mentioned, the posterior belly

of the digastric muscle and the hypoglosal nerve.

The sutures are attached to the superior

skin-subplatysmal flap.

(Surg-7 Click here to enlarge the picture)

(8)

(8)

Surgical specimen to be sent to pathology.

(Surg-8 Click here to enlarge the picture)

Pathology

Cystic hygroma

References for further reading:

1) Clary R. A., Lusk R. P.:Neck Masses, Chapter 95 in Pediatric Otolaryngology, (Bluestone, Stool, Kenna, editors), Volume Two, Third Edition, Saunders, pp. 1488-1496, 1996

2) Rood S.R., Johnson J. T., Lipman S.P., Myers E.N.: Diagnosis and Management of Congenital Head and Neck Masses, ASelf-Instructional Package from the Committee on Continuing Education in Otolaryngology, American Academy ofOtolaryngology-Head and Neck Surgery Foundation

3) Richardson M.A., Rosenfeld R.M.: Congenital Malformations of the head and neck, Chapter 22 in Surgical Atlas of Pediatric Otolaryngology (Bluestone C.D., Rosenfeld R. M., editors) B.C. Decker, pp. 496-498, 2002.

Discussion: Cystic Hygroma is a benign congenital neck mass of lymphatic origin. Cystic hygroma can range from a small isolated mass to a massive lesion. The clinical picture is usually the one of an asymptomatic mass.

Cystic hygroma are usually present at birth. 70-80% of these lesions are diagnosed by the second or third year of life. Males and females are affected equally.

Depending of the size and location, associated symptoms (such as dyspnea, dysphagia, stridor) can occur due to compression of the upper aerodigestive tract and/or other vital structures.

The diagnosis is usually evident on physical examination and confirmed by CT scanning or MRI and ultrasonography.

The treatment is usually surgical, preventing any damage to the adjacent vital structures of the neck (in this case: internal jugular vein, vagus, hypoglossal

and recurrent nerves, carotid artery and esophagus).

The case presented required a neck dissection at the

level II, III and IV of the neck. Therefore, this is considered a lateral neck dissection.

Click below to enlarge the above group of pictures

Enlarge pictures

Acknowledgment:

To all of the patients who have taught me so much.

To Dr. Hector Garcia for his participation and assistance in the case.

Any comments or questions regarding the above,

please notify at ariera@spray.no